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Journal of Assisted Reproduction and... Jan 2014To evaluate the efficacy of luteal phase support with vaginal progesterone in women undergoing intrauterine insemination (IUI). (Meta-Analysis)
Meta-Analysis Review
PURPOSE
To evaluate the efficacy of luteal phase support with vaginal progesterone in women undergoing intrauterine insemination (IUI).
METHODS
Systematic review and meta-analysis. Randomized controlled trials (RCT) comparing supplementation of luteal phase with vaginal progesterone among women undergoing IUI versus a control group were included. The main outcome assessed was live birth rate.
RESULTS
Five RCT met the inclusion criteria. In all 1,271 patients were included (951 IUI cycles in the progesterone group, 935 in the control group). Women treated with vaginal progesterone achieved significantly higher live birth rate (risk ratio [RR] 1.94, 95 % confidence interval [CI] 1.36 to 2.77,), and clinical pregnancy rate (RR 1.41, 95 % CI 1.14 to 1.76) as compared with controls. In the subgroup analysis per stimulation protocol, this beneficial effect of receiving progesterone was only observed in the group stimulated with gonadotropins (RR 2.28, 95 % CI 1.49 to 3.51), compared to the group stimulated with clomiphene citrate (CC) (RR 1.30, 95 % CI 0.68 to 2.50). No differences were observed in the miscarriage and multiple pregnancy rates.
CONCLUSIONS
The supplementation of luteal phase with vaginal progesterone significantly increases live birth among women undergoing IUI when receiving gonadotropins for ovulation induction. Women receiving CC to induce ovulation do not seem to benefit from this treatment.
Topics: Administration, Intravaginal; Female; Humans; Infertility; Insemination, Artificial; Luteal Phase; Male; Pregnancy; Pregnancy Rate; Progesterone; Randomized Controlled Trials as Topic; Treatment Outcome
PubMed: 24189966
DOI: 10.1007/s10815-013-0127-6 -
Fertility and Sterility Nov 2013To evaluate the effect of luteal phase P support after ovulation induction IUI. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To evaluate the effect of luteal phase P support after ovulation induction IUI.
DESIGN
A systematic review and meta-analysis.
SETTING
Not applicable.
PATIENT(S)
Undergoing ovulation induction IUI.
INTERVENTION(S)
Any form of exogenous P in ovulation induction IUI cycles.
MAIN OUTCOME MEASURE(S)
Clinical pregnancy and live birth.
RESULT(S)
Five trials were identified that met inclusion criteria and comprised 1,298 patients undergoing 1,938 cycles. Clinical pregnancy (odds ratio [OR] 1.47, 95% confidence interval [CI] 1.15-1.98) and live birth (OR 2.11, 95% CI 1.21-3.67) were more likely in P-supplemented patients. These findings persisted in analyses evaluating per IUI cycle, per patient, and first cycle only data. In subgroup analysis, patients receiving gonadotropins for ovulation induction had the most increase in clinical pregnancy with P support (OR 1.77, 95% CI 1.20-2.6). Conversely, patients receiving clomiphene citrate (CC) for ovulation induction showed no difference in clinical pregnancy with P support (OR 0.89, 95% CI 0.47-1.67).
CONCLUSION(S)
Progesterone luteal phase support may be of benefit to patients undergoing ovulation induction with gonadotropins in IUI cycles. Progesterone support did not benefit patients undergoing ovulation induction with CC, suggesting a potential difference in endogenous luteal phase function depending on the method of ovulation induction.
Topics: Clomiphene; Drug Administration Schedule; Female; Fertility Agents, Female; Humans; Infertility; Insemination, Artificial; Live Birth; Luteal Phase; Male; Odds Ratio; Ovulation Induction; Pregnancy; Pregnancy Rate; Progesterone; Treatment Outcome
PubMed: 23876537
DOI: 10.1016/j.fertnstert.2013.06.034 -
Asian Journal of Andrology Jul 2013Male factor infertility affects 30%-50% of infertile couples worldwide, and there is an increasing interest in the optimal management of these patients. In studies... (Meta-Analysis)
Meta-Analysis Review
Male factor infertility affects 30%-50% of infertile couples worldwide, and there is an increasing interest in the optimal management of these patients. In studies comparing double and single intrauterine insemination (IUI), a trend towards higher pregnancy rates in couples with male factor infertility was observed. Therefore, we set out to perform a meta-analysis to examine the superiority of double versus single IUI with the male partner's sperm in couples with male factor infertility. An odds ratio (OR) of 95% confidence intervals (CIs) was calculated for the pregnancy rate. Outcomes were analysed by using the Mantel-Haesel or DerSimonian-Laird model according to the heterogeneity of the results. Overall, five trials involving 1125 IUI cycles were included in the meta-analysis. There was a two-fold increase in pregnancies after a cycle with a double IUI compared with a cycle with a single IUI (OR: 2.0; 95% CI: 1.07-3.75; P<0.03). Nevertheless, this result was mainly attributed to the presence of a large trial that weighted as almost 50% in the overall analysis. Sensitivity analysis, excluding this large trial, revealed only a trend towards higher pregnancy rates among double IUI cycles (OR: 1.58; 95% CI: 0.59-4.21), but without statistical significance (P=0.20). Our systematic review highlights that the available evidence regarding the use of double IUI in couples with male factor infertility is fragmentary and weak. Although there may be a trend towards higher pregnancy rates when the number of IUIs per cycle is increased, further large and well-designed randomized trials are needed to provide solid evidence to guide current clinical practice.
Topics: Clinical Trials as Topic; Female; Humans; Infertility, Male; Insemination, Artificial; Male; Pregnancy; Pregnancy Rate
PubMed: 23708457
DOI: 10.1038/aja.2013.4 -
Fertility and Sterility Mar 2009To systematically review the literature to identify randomized controlled trials, which evaluate interventions aiming to improve the probability of pregnancy in poor... (Meta-Analysis)
Meta-Analysis Review
OBJECTIVE
To systematically review the literature to identify randomized controlled trials, which evaluate interventions aiming to improve the probability of pregnancy in poor responders undergoing in vitro fertilization (IVF).
DESIGN
Systematic review and meta-analysis.
SETTING
University-based hospital.
INTERVENTION(S)
None.
MAIN OUTCOME MEASURE(S)
Pregnancy rate.
RESULT(S)
Twenty-two eligible randomized controlled trials were identified that evaluated in total 15 interventions to increase pregnancy rates in poor responders. Based on limited evidence, the only interventions that appear to increase the probability of pregnancy were the addition of GH to ovarian stimulation (odds ratio for live birth: 5.22, confidence interval: 95% 1.09-24.99) and the performance of embryo transfer on day 2 compared with day 3 (ongoing pregnancy rate: 27.7% vs. 16.3%, respectively; difference: +11.4, 95% confidence interval: +1.6 to +21.0).
CONCLUSION(S)
Insufficient evidence exists to recommend most of the treatments proposed to improve pregnancy rates in poor responders. Currently, there is some evidence to suggest that addition of GH, as well as performing embryo transfer on day 2 versus day 3, appear to improve the probability of pregnancy.
Topics: Administration, Cutaneous; Administration, Oral; Drug Administration Schedule; Drug Therapy, Combination; Embryo Culture Techniques; Embryo Transfer; Evidence-Based Medicine; Female; Fertility Agents, Female; Fertilization in Vitro; Growth Hormone; Humans; Insemination, Artificial; Odds Ratio; Oocyte Retrieval; Ovulation Induction; Pregnancy; Pregnancy Rate; Probability; Sperm Injections, Intracytoplasmic; Time Factors; Treatment Outcome
PubMed: 18639875
DOI: 10.1016/j.fertnstert.2007.12.077 -
The Cochrane Database of Systematic... Apr 2008Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples... (Review)
Review
BACKGROUND
Insemination with donor sperm is an option for couples for whom in vitro fertilisation (IVF) or intra-cytoplasmic sperm injection (ICSI) has been unsuccessful, couples with azoospermia and for single women or same sex couples. Insemination of sperm can be done via cervical (CI) or intra-uterine (IUI) routes. IUI has been considered potentially more effective than CI as the sperm bypasses the cervical mucus and is deposited closer to the fallopian tubes. The cost and risks of IUI may be higher because of the need for sperm preparation and the introduction of foreign material into the uterus. Donor sperm used for artificial insemination is mainly cryopreserved, due to concerns about HIV transmission. However, cycle fecundity is higher for fresh sperm. Insemination is often combined with ovulatory stimulation, with either clomiphene or gonadotrophin. There may be risks associated with these therapies, such as higher multiple pregnancy rates.
OBJECTIVES
To determine whether pregnancy outcomes are improved using intra-uterine insemination in comparison to cervical insemination in women undergoing artificial insemination with donor sperm.
SEARCH STRATEGY
The following databases were searched: the Cochrane Menstrual Disorders and Subfertility Group Specialised Register, CENTRAL (The Cochrane Library) , MEDLINE, EMBASE, CINAHL and the reference lists of articles retrieved.
SELECTION CRITERIA
Randomised controlled trials comparing IUI with CI were included. Crossover studies were included if pre-crossover data was available.
DATA COLLECTION AND ANALYSIS
Study quality assessment and data extraction were carried out independently by two review authors (DB, JM). Authors of studies that potentially met the inclusion criteria were contacted, where possible if additional information was needed.
MAIN RESULTS
The search strategy found 232 articles. Fifteen studies potentially met the inclusion criteria. Four studies were included in this review. All the included studies used cryopreserved sperm in stimulated cycles. In two studies 134 women had gonadotrophin-stimulated cycles and in two studies 74 women had clomiphene-stimulated cycles. The evidence showed that IUI after 6 cycles significantly improved live birth rates (odds ratio (OR) 1.98, 95% confidence interval (CI) 1.02 to 3.86) and pregnancy rates (OR 3.37, 95% CI 1.90 to 5.96) in comparison to cervical insemination. There was no statistically significant evidence of an effect on multiple pregnancies (OR 2.19, 95% CI 0.79 to 6.07) or miscarriages (relative risk (RR) 3.92, 95% CI 0.85 to 17.96).
AUTHORS' CONCLUSIONS
The findings of this systematic review support the use of IUI rather than CI in stimulated cycles using cryopreserved sperm for donor insemination.
Topics: Cervix Uteri; Cryopreservation; Female; Humans; Insemination, Artificial, Heterologous; Pregnancy; Pregnancy Rate; Randomized Controlled Trials as Topic; Semen Preservation; Uterus
PubMed: 18425862
DOI: 10.1002/14651858.CD000317.pub3 -
The Cochrane Database of Systematic... Apr 2007Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been demonstrated to be an effective form of treatment for subfertile couples. Several... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Intrauterine insemination (IUI) combined with ovarian hyperstimulation (OH) has been demonstrated to be an effective form of treatment for subfertile couples. Several ovarian stimulation protocols combined with IUI have been proposed, but it is still not clear which stimulation protocol and which dose is the most cost-effective.
OBJECTIVES
To evaluate ovarian stimulation protocols for intrauterine insemination for all indications.
SEARCH STRATEGY
We searched for all publications which described randomised controlled trials comparing different ovarian stimulation protocols followed by IUI. We searched the Menstrual Disorders and Subfertility Group's Central register of Controlled Trials (CENTRAL). We searched the electronic databases of MEDLINE (January 1966 to present) and EMBASE (1980 to present).
SELECTION CRITERIA
Randomised controlled trials only were considered for inclusion in this review. Trials comparing different ovarian stimulation protocols combined with IUI were selected and reviewed in detail.
DATA COLLECTION AND ANALYSIS
Two independent review authors independently assess trial quality and extracted data.
MAIN RESULTS
Forty three trials involving 3957 women were included. There were 11 comparisons in this review. Pregnancy rates are reported here since results of live birth rates were lacking. Seven studies (n = 556) were pooled comparing gonadotrophins with anti-oestrogens showing significant higher pregnancy rates with gonadotrophins (OR 1.8, 95% CI 1.2 to 2.7). Five studies (n = 313) compared anti-oestrogens with aromatase inhibitors reporting no significant difference (OR 1.2 95% CI 0.64 to 2.1). The same could be concluded comparing different types of gonadotrophins (9 studies included, n = 576). Four studies (n = 391) reported the effect of adding a GnRH agonist which did not improve pregnancy rates (OR 0.98 95% CI 0.6 to 1.6), although it resulted in significant higher multiple pregnancy rates (OR 2.9 95% CI 1.0 to 8). Data of three studies (n = 299) showed no convincing evidence of adding a GnRH antagonist to gonadotrophins (OR 1.5 95% CI 0.83 to 2.8). The results of two studies (n = 297) reported no evidence of benefit in doubling the dose of gonadotrophins (OR 1.2 95% 0.67 to 1.9) although the multiple pregnancy rates and OHSS rates were increased. For the remaining five comparisons only one or none studies were included.
AUTHORS' CONCLUSIONS
Robust evidence is lacking but based on the available results gonadotrophins might be the most effective drugs when IUI is combined with ovarian hyperstimulation. When gonadotrophins are applied it might be done on a daily basis. When gonadotrophins are used for ovarian stimulation low dose protocols are advised since pregnancy rates do not differ from pregnancy rates which result from high dose regimen, whereas the chances to encounter negative effects from ovarian stimulation such as multiples and OHSS are limited with low dose gonadotrophins. Further research is needed for each comparison made.
Topics: Estrogen Antagonists; Female; Gonadotropin-Releasing Hormone; Gonadotropins; Humans; Infertility; Insemination, Artificial; Ovulation Induction; Randomized Controlled Trials as Topic
PubMed: 17443584
DOI: 10.1002/14651858.CD005356.pub2 -
The Cochrane Database of Systematic... Oct 2005The postcoital test has poor diagnostic and prognostic characteristics. Nevertheless, some physicians believe it can identify scanty or abnormal mucus that might impair... (Review)
Review
BACKGROUND
The postcoital test has poor diagnostic and prognostic characteristics. Nevertheless, some physicians believe it can identify scanty or abnormal mucus that might impair fertility. One way to avoid 'hostile' cervical mucus is intrauterine insemination. With this technique, the physician injects sperm directly into the uterine cavity through a small catheter passed through the cervix; the theory is to bypass the "hostile" cervical mucus. Although most gynaecological societies do not endorse use of intrauterine insemination for hostile cervical mucus, some physicians consider it an effective treatment for women with infertility thought due to cervical mucus problems.
OBJECTIVES
The aim of this review was to determine the effectiveness of intrauterine insemination with or without ovarian stimulation in women with cervical hostility who failed to conceive.
SEARCH STRATEGY
We searched Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library Issue 2, 2005, MEDLINE (1966 to June 2005), EMBASE (1980 to June 2005), POPLINE (to June 2005) and LILACS (to June 2005). In addition, we contacted experts and searched the reference list of relevant articles and book chapters.
SELECTION CRITERIA
We included randomized and quasi-randomized controlled trials comparing intrauterine insemination with intercourse timed at the presumed fertile period. Participants were women with cervical hostility who failed to conceive for at least one year.
DATA COLLECTION AND ANALYSIS
We assessed the titles and abstracts of 386 publications and two reviewers independently abstracted data on methods and results from five studies identified for inclusion. The main outcome is pregnancy rate per couple.
MAIN RESULTS
We did not pool the outcomes of the included five studies in a meta-analysis due to the methodological quality of the trials and variations in the patient characteristics and interventions. Narrative summaries of the outcomes are provided. Each study was too small for a clinically relevant conclusion. None of the studies provided information on important outcomes such as spontaneous abortion, multiple pregnancies, and ovarian hyperstimulation syndrome.
AUTHORS' CONCLUSIONS
There is no evidence from the published studies that intrauterine insemination is an effective treatment for cervical hostility. Given the poor diagnostic and prognostic properties of the postcoital test and the observation that the test has no benefit on pregnancy rates, intrauterine insemination (with or without ovarian stimulation) is unlikely to be a useful treatment for putative problems identified by postcoital testing.
Topics: Biomarkers; Cervix Mucus; Coitus; Female; Humans; Infertility; Insemination, Artificial, Homologous; Luteinizing Hormone; Time Factors
PubMed: 16235303
DOI: 10.1002/14651858.CD002809.pub2